Physical Assessment

Front 1

begin the exam noting:

Back 1

vital signs are all within normal limits
my patient is ANOx3 and in no acute distress
her visual acuity has been testing using the Snelling chart, which is a test of cranial nerve II, the Optic Nerve

Front 2

Hello, I'm Sarah Archenbronn, I'll be doing your physical assessment today.

Back 2

I inspect her skin, looking for color, legions and hair distribution.

Front 3

Then I'm going to palpate...

Back 3

for moisture, temperature, mobility and turgor: inspecting bilaterally.

Front 4

Then I go to the fingernails...

Back 4

check for clubbing and pitting, as well as, checking capillary refill is under 3 seconds. I’ll be checking the skin throughout the remainder of the exam.

Front 5

Moving onto the head...

Back 5

I’m going to first visually inspect for size and contour.

Front 6

“Can I touch your head?”

Back 6

I’m going to palpate for tenderness and any deformities. I can now say that my patient is normocephallic atraumatic.

Front 7

Looking at her scalp...

Back 7

for inhabitants or legions, feeling her hair for its texture; noting color, distribution and any patterns of loss.

Front 8

Now I can move onto her face

Back 8

noting general symmetry. Eyebrows present, equal bilaterally, nose is midline and lateral canthus of her eyes is inline with the helix of her ears.

Front 9

Test for cranial nerve VII,

Back 9

the facial nerve.
“Could you smile? Frown? Puff out your cheeks? Raise your eyebrows? Close your eyes and try to not let me open them.”

Front 10

Now I’m going to test cranial nerve V,

Back 10

the Trigeminal nerve, starting with the sensory portion.

“Close your eyes, tell me when you feel my finger.”

Front 11

Now I’m going to test the motor portion of cranial nerve V

Back 11

by touching her masseter muscle.
“Can you clench your teeth?”
I’m feeling her masseter muscle engage.

Front 12

Now I’m going to assess the temporomandibular joint.

Back 12

“Could you open and close your mouth?”
I’m assessing for crepitus and popping.

Front 13

Then I am going to check her temporal arteries...

Back 13

looking for any induration and the pulse is 2+ equal bilaterally.

Front 14

Done with the face, moving onto the eyes.

Back 14

First visually inspecting the eyelashes that the go up and out on the top and down and out on the bottom, pupils are round and equal bilaterally, the sclera is white.

Front 15

“Can you look up?”

Back 15

The conjunctiva is pink and moist.

Front 16

Now I’m going to test convergence and accommodation.

Back 16

“Follow my finger with your eyes”
Noting that the pupils constrict and the eyes converge as my finger moves in, the pupils dilate and the eyes go out as I move away. This is a test for cranial nerves II, III, the Optic and Oculomotor.

Front 17

“Look straight ahead and tell me when you see my fingers”

Back 17

This test is called visual fields by confrontation, which tests peripheral vision and cranial nerve II.

Front 18

Now I’m going to do the 6 cardinal fields of gaze, which is a test of extraocular movements.

Back 18

“Can you follow my finger with your eyes again?”
This is tests cranial III, IV and VI the Oculomotor, Trochlear and Abducens. I’m looking for nystagmus, which would only be normal in the extreme lateral gaze.

Front 19

Now I’m going to take my pen light for a few more tests.

Back 19

First, corneal light reflex, I’m shining the light checking that it reflects off the same place in both eyes, this is a test for strabismus.

Front 20

Next direct and consensual pupillary light reflex,

Back 20

first seeing that her pupil constricts when i shine a light in it, that is direct constriction, now looking at the other eye and seeing that it constricts consensually. I’m doing this bilaterally. An that tests cranial nerves II & III.

Front 21

I can now say that my patient is

Back 21

PERLA and EOMI.

Front 22

I’m taking my opthalmascope

Back 22

going right eye to right eye, first seeing the red light relex,

Front 23

then move in, I’m looking at the

Back 23

retinal background for four sets of vessels. Identifying the optic disc, noting it is creamy yellow with clearly defined margins and that the macula is 2 optic disc diameters away. Do this bilaterally, identifying the same structures in the other eye.

Front 24

Now I’m going to move onto the ears, switching to an odoscope. First I’m going to test

Back 24

her gross hearing, which is the test for cranial nerve VIII, the vestibulocochlear nerve.
“Can you close your eyes and point to the ear where you hear something?”

Front 25

Now I’m going to inspect the auricles for

Back 25

legions, especially behind and on top, this is a common site for skin cancer.

Front 26

Now palpating the tragus

Back 26

and mastoid process for tenderness.
“Do you feel any tenderness?”

Front 27

Now I can proceed with my odoscope. I’m pulling the pinna up and back.

Back 27

First I inspect the external ear canal for inflammation, excess cerumin or foreign bodies.

Front 28

Then seeing the tympanic membrane,

Back 28

that it is a pearly grey color and that I can see the boney prominences of the middle ear and that there is a cone of light at 7 o’clock in left ear and 5 o’clock in the right ear.

Front 29

Onto the nose...

Back 29

“Can you occlude one nostril and breath through the other, now the other side?” I’m checking for patency in each nostril.

Front 30

I’m also going to check the sinuses.

Back 30

“Do you feel any tenderness?”
I palpate the maxillary sinus and frontal sinus.

Front 31

Going into her nostril with the fundascope I’m checking that her nasal septum

Back 31

is not perforated or deviated, the nasal mucosa is red and moist, i can identify the inferior and middle turbinates, there are no excessive exudate or polyps. Looking for the same things on the other nostril.

Front 32

Move onto the mouth now, first thing I’m visually inspecting

Back 32

the lips for any legions and for color,

Front 33

“Can you smile and then open your mouth”

Back 33

I’m looking for general dentition and gums,

Front 34

i need a tongue blade and light.

Back 34

Now going to look at her buccal mucosa, it should be pink and moist. Identifying the Stensons duct, which is above the second molar on the top on both sides.

Front 35

checking the tongue for

Back 35

legions both on top and underneath,
“Can you lift up your tongue?”
also identifying the Warton’s duct under the tongue.

Front 36

“Could you open your mouth and say Ah.”

Back 36

looking back to see that her uvula remains midline and that her soft palate rises and falls. while im back there im grading the tonsils and that is a test for cranial nerves IX and X, the Glossopharangeal and Vagus nerves.

Front 37

“Now could you stick out your tongue and move it side to side”

Back 37

This is a test of cranial nerve XII, the Hypoglossal nerve.

Front 38

“Could you turn your head against my hand, now other side. Can you raise your shoulders?”

Back 38

That’s cranial nerve XI, the Accessory nerve. I can now say that cranial nerves 2-12 are intact.

Front 39

Moving onto the neck, I’m visually inspecting for

Back 39

masses or pulsations, now I’m going to palpate to ensure that the trachea is midline.

Front 40

palpate the carotid pulses on the upper 1/3 bilaterally - grade at 2+

Back 40

then listen with the bell of the stethoscope for bruits, have the patient hold their breath while doing this.

Front 41

Now I’m going to assess the cervical lymph nodes.

Back 41

The first are the prearicular, posterior auricular,
the occipital,
(tonsillar),
submandibular,
submental,
the superficial cervical,
the posterior cervical,

Front 42

“Can you bend your head to one side?”

Back 42

the deep cervical chain.

Front 43

“Now, the other side. Can you haunch your shoulders up a bit”

Back 43

this is the superclavicular and the infraclavicular. I expect all these lymph nodes to be non-palpable, or if they are palpable to be less than 1cm, soft, mobile and non-tender.

Front 44

Now I’m moving around to the thyroid. I locate it and then float it to one side and then palpate the other side.
“Could you swallow?”
I’m feeling while she swallows, now to the other side.
“Swallow again”

Back 44

The thyroid should be non-tender, non-enlarged and non-nodular.

Front 45

“Can you take your gown down?”
I’m going to start with the posterior thorax.

Back 45

First I’m inspecting for rate and rhythm of respiration and general respiratory effort.

Front 46

Now I’m going to palpate the spine, starting at the top,

Back 46

Im just palpating to make sure that it is not deviated and not tender.
“Do you feel any tenderness?”

Front 47

Now I can assess respiratory excursion

Back 47

at the level of the 10th rib.
“Could you take a deep breath in and out?”
I watch my thumbs move apart and together symmetrically.

Front 48

Now I’m going to to tactile fremitus in 4 paired spots.

Back 48

“Just say 99 when I touch you”
The vibrations should be equal symmetrically and diminish as I go down.

Front 49

Now I’m going to percuss in 7 paired spots on the back,

Back 49

looking for resonance throughout the lung field.

Front 50

Now I’m going to percuss for diaphragmatic excursion.

Back 50

“Could you take a deep breath in and then breathe out and hold it out.”
Start where I think her diaphragm is and then percuss until I hit dullness.

Front 51

“Now take a deep breath in and hold it in.”

Back 51

Then it should be resonate again, and i will percuss down until I hit dullness. The distance between the exhale and inhale should be about 3-5cm and I’m going to check that it’s equal bilaterally.

Front 52

Now using the diaphragm of the stethoscope I’m going to ascultate her lung fields in the same 7 spots that I percussed,

Back 52

listening for bronchovesicular and vesicular lung sounds through the lung fields noting any adventitious breaths. I would have my patient take a full inhale and exhale at each of these spots through her mouth, but I’m just going to show the spots.

Front 53

Percuss at two spots on the lower back for...

Back 53

CVA tenderness

Front 54

Then I’m going to move around front noting AP diameter it...

Back 54

should be 2:1 This is also where I like to listen to the right middle lobe at the 5th intercostal mid-axillary line.
“Could you lift your arm a little bit?”
Again a full inhale and exhale, looking for the same sounds that I heard on the back.

Front 55

So, on the front I’m going to assess respiratory excursion again.
“Could you take a deep breath in and out?”

Back 55

Watching for the symmetry in my hands as we did on the back.

Front 56

Now tactile fremitus on...

Back 56

Now tactile fremitus on 3 pairs spots using the palmar surfaces of my hands.
“Could you say 99 when I touch you”

Front 57

I’m going to percuss for...

Back 57

resonance in the lung fields beginning above the clavicle in 6 paired spots. Resonance throughout.

Front 58

I’m going to ascultate with the diaphragm of my stethoscope in the same 6 spots.

Back 58

I would have my patient take a full inhale and exhale at each of these spots through her mouth, but I’m just going to show the spots.

Front 59

Have patient lean forward and using the...

Back 59

diaphragm of the stethoscope I listen at the aortic and pulmonic locations for a high pitched murmur.

Front 60

Moving onto the breasts and axilla now. First visually inspecting for any

Back 60

retractions.
“Could you put your arms above your head? At your hips? And then lean forward?”

Front 61

Now I’m going to check the axillary lymph nodes.
“Just hang your arm like a doll.”

Back 61

I’m feeling the pectoral, the subscapular, the deep central and following the lateral chain to the epitrochlear. I’m going to do this bilaterally. I expect the same finding as with the cervical lymph nodes.

Front 62

I’m going to continue the breast exam with my patient lying down.
“Could you put your gown back on and lay down for me? Lift this arm over your head”

Back 62

I’m uncovering one breast at a time and palpating, being sure to cover all the breast tissue, paying particular attention to the tail of spence in women, and deep into the nipple in men.

Front 63

I’m palpate the nipples checking for any discharge. (both directions, both breasts)

Back 63

I’m assessing for consistency, nodules or masses, and any tenderness while I do that. Same thing on the other side, moving the other arm up, and I would take this opportunity to educate my patient on self breast exam.

Front 64

(adjust the bed to 30degrees)

Back 64

Then locate the angle of Louis, at the 2nd rib & sternum, and the right internal jugular vein.

Front 65

“Can you turn your head to the left?”

Back 65

Measure the height of pulsation up the right internal jugular and add 5cm. This is the jugular vein distention, it should be less than 9cm. (this reflects the pressure in the right atrium)

Front 66

Then palpate for thrills at the aortic, pulmonic, tricuspid and mitral.
aortic is located at right sternal border 2nd intercostal space
pulmonic is at the left sternal border 2nd intercostal space
tricuspid is at the left sternal border 5th intercostal space
mitral at 5th intercostal space, mid-clavicular

Back 66

(with the palmar surface of your hand) grading all murmurs between 1-6. Now palpating for the point of maximal impulse (with fingertips).

Front 67

Ascultating with the diaphragm at the

Back 67

aortic, pulmonic, Erb’s point located at the left sternal border 3rd intercostal space, tricuspid and mitral listening for heart sounds: especting to hear hear S2 louder at aortic/pulmonic, equal at erbs and S1 louder at tricuspid/mitral.

Front 68

Using the bell of the stethoscope i listen again at the

Back 68

same locations for murmurs, finally listening at the PMI with the bell while having the patient lay in the left lateral decubitous position.

Front 69

I'll ask the patient to

Back 69

put their knees up for the abdominal exam

Front 70

Then inspecting the abdomen looking for

Back 70

pulsations, scarring, contour and masses.

Front 71

I’ll use the bell of my stethoscope to listen at the

Back 71

aortic, renal, illiac and femoral locations for bruits.

Front 72

Then I’ll ascultate, using the diaphragm of stethoscope, the abdomen following along the colon.

Back 72

5-35 bowel sounds/min should be heard, if no sounds are heard i listen for 1 minute per/quadrant.

Front 73

Then I will percuss the abdomen in 10 spots,

Back 73

and I should hear tympany at each location.

Front 74

Then I will percuss the right sternal border going from tympany to dullness to ascertain the size of the liver.

Back 74

This measure should be 4-8 cm. If I had done the midclavicular line it would have been 6-12 cm.

Front 75

Next I move onto the left mid axillary, percussing from resonance to tympany.

Back 75

If dullness was heard it would indicate an enlarged spleen and I would percuss medially and anteriorly.

Front 76

I start with a light palpation for

Back 76

tenderness in the abdomen, then move into deep palpation for masses and underlying structures.

Front 77

Then hook my hands under the right rib cage
“Can you inhale and exhale?”

Back 77

the liver should be non-enlarged, no nodules and non-tender.

I should not feel the spleen at this time or it would be enlarged.

Front 78

I’m then moving to check on the kidneys bilaterally.

Back 78

duck bill, have pt breathe in and out

Front 79

I’ll find the aortic pulsation in the stomach,

Back 79

it should be under 3cm.

Front 80

I’ll move on to check the pulses bilaterally:

Back 80

radial, ulnar, brachial, femoral,

Front 81

while by the femoral I will palpate the

Back 81

ingunal lymph nodes. The may be palpable, but should be under 2cm, non-tender, soft and mobile.

Front 82

continuing with the pulses

Back 82

popliteal , posterior tibial [MEDIAL], dorsalis pedis I can now say that all pulses are graded 2+ bilaterally.

Front 83

Moving onto the legs: I’m looking for signs of

Back 83

arterial and venous insufficiency, specifically pigmentation, legions, and hair distribution.

Front 84

I’m going to palpate the

Back 84

temperature using the backs of my hands, and inspect for pretibial edema and pitting edema in the feet. Check capillary refill in each toe is under 3 seconds.

Front 85

Moving onto the musculoskeletal system; palpate

Back 85

DIP (distal intraphelangial) and PIPs (proximal intraphelangial) for bogginess or tenderness. check range of motion in hands, wrists, and elbows. I checked range of motion in the shoulder during the breast exam.

Front 86

I then move onto the hips, checking

Back 86

hip adduction and abduction, knee flexion, internal and external rotation of the hip. I’ll rotate the ankles. All of this is done bilaterally.

Front 87

Check the plantar reflex of each foot,

Back 87

looking for the toes to curl under. {do we have to explain babinski?}

Front 88

Next I will check the deep tendon reflexes:

Back 88

branchial radial, bicep, tricep, patellar, and achilles. I grade her reflexes at a 2+ bilaterally.

Front 89

Now I’m going to assess her muscle tone.

Back 89

Inspecting patient for general muscle bulk and tone.

Front 90

“Resist me when I push and pull” (elbows)

Back 90

“Spread your fingers and dont let me push them together. Grip my two fingers as hard as you can. Resist me when I push on your quad. Resist when I push and pull on your calves and then feet.”
I can now say I can grade her strength 5/5 bilaterally.

Front 91

I’m now going to test her spinothalamic tract first starting with the pain sensation test

Back 91

“This is sharp, and this is dull. close your eyes and tell me which you feel” (hands, arms u/l, legs u/l and feet)

Front 92

I’m now going to assess her light touch sensation

Back 92

(cotton ball)
“Tell me when you feel it touch you.”
I can now say that her spinothalamic tract is in tact.

Front 93

Now I will assess her posterior column tract.

Back 93

“I’m going to touch this instrument to your thumbs and great toes. Close your eyes and tell me when you stop feeling the vibration.”

Front 94

Proprioception

Back 94

“This is up and this is down. Close your eyes and tell me which direction I move your thumbs and great toes.” (make sure to hold the :sides: of the joint)

Front 95

I’m going to test her fine tactile sense.

Back 95

“Now I’m going to draw a number in the palm of your hand. Tell me what number I draw” (graphesthesia)
I can now say her posterior column is in tact.

Front 96

We can test her cerebellar function, starting with rapid alternating movements.

Back 96

“Please place your forefinger and thumb together as fast as you can. Patty cake on your legs as fast as you can. flop your feet as fast as you can.”

Front 97

now a test of point to point coordination

Back 97

“Put your index finger on your nose and then extend it to my finger.”
I’m looking for tremors as she extends her hand. I’m making sure she crosses her midline and that the test is done bilaterally. “Can you run the heel of your foot down the shin of your other leg? Now with the other leg?”

Front 98

“please stand up for the next portion.

Back 98

i’m going to have you roll your head. bend forward and backward, then side to side.”
This is a test of her range of motion in her neck and spine.

Front 99

“now put your feet together and close your eyes”

Back 99

I would have her hold this position for 20-30 seconds. If she were to take a step forward or sway excessively that would indicate a positive result for Romberg test.

Front 100

“Now stand normally, please place your arms out in front of you with your palms facing upward.”

Back 100

I would have her hold this position for 20-30 seconds to test for pronation and drift. (push down on arms test) looking for over or under compensation.

Front 101

close the exam with?

Back 101

I would then have her walk 10 steps away from me and back to assess her gait.

Front 102

vessels have bruits

Back 102

the heart has murmurs

Front 103

EOMI

Back 103

Extra Ocular movement intact

Front 104

PERLA

Back 104

Pupils Equal Round and Reactive to Light and Accomodation